Treatment Evidence Form
Unit 823 – Provide Body Electrotherapy Treatments
College Name:
College Number:
Learner Name:
Learner Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
30–40
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
40–50
50–60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical
permission cannot be obtained clients must give their informed consent in writing prior to treatment
(select if/where appropriate):
Pregnancy
Any dysfunction of the nervous system (e.g.
Cardio vascular conditions (thrombosis, phlebitis,
Multiple Sclerosis, Parkinson’s disease, Motor
hypertension, hypotension, heart conditions)
Neurone disease)
Haemophilia
Bells Palsy
Any condition already being treated by a GP or
Trapped/Pinched nerve (e.g. sciatica)
another practitioner
Inflamed nerve
Medical oedema
Cancer
Osteoporosis
Postural deformities
Arthritis
Cervical spondylitis
Nervous/Psychotic conditions
Spastic conditions
Epilepsy
Kidney infections
Recent operations
Whiplash
Diabetes
Slipped disc
Asthma
Undiagnosed pain
Chemotherapy
When taking prescribed medication
Radiotherapy
Acute rheumatism
Medication causing thinning/inflammation of the skin
Diagnosed scleroderma
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissue (2 years for major operation and 6
months for a small scar)
Sunburn
Recent dermabrasion or chemical peels
Recent IPL, laser and/or epilation
Unit 823 Provide Body Electrotherapy Treatments
(select if/where appropriate):
Hormonal implants
Menstruation (abdomen - first few days)
Haematoma
Hernia
Recent fractures (minimum 3 months)
Gastric ulcers
After a heavy meal
Conditions affecting the neck
Any metal pins or plates
Loss of skin sensation (test with tactile test)
IUD (coil)
Anaphylaxis
Muscle fatigue
Pacemaker
Body piercing
Excessive erythema
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WRITTEN PERMISSION REQUIRED BY:
GP/Specialist
Informed consent
Either of which should be attached to the consultation form
PERSONAL INFORMATION (select if/where appropriate):
Muscular/Skeletal problems: Back
Aches/Pain
Digestive problems: Constipation
Circulation: Heart
Kidney problems
Bloating
Blood pressure
Stiff joints
Headaches
Liver/Gall bladder
Fluid retention
Stomach
Tired legs
Varicose veins
Cellulite
Cold hands and feet
Gynaecological: Irregular periods
Nervous system: Migraine
P.M.T
Tension
Immune system: Prone to infections
Menopause
Stress
Herbal remedies taken: Yes
No
Ability to relax: Good
Moderate
Sleep patterns: Good
Poor
No
Colds
Other:
Chest
Sinuses
If yes, type and name of medication
Poor
No. of hours:
Do you see natural daylight in your workplace? Yes
Do you work at a computer? Yes
Do you eat in a hurry? Yes
Coil
If yes, type and name of remedy
Average
Do you eat regular meals? Yes
Pill
Depression
Sore throats
Regular antibiotic/medication taken: Yes
H.R.T
No
No
If yes, how many hours:
No
No
Do you take any food/vitamin supplements? Yes
No
If yes, type and name of supplement(s)
How many portions of each of these items does your diet contain per day?
Fresh fruit:
Fresh vegetables:
Dairy produce:
Protein:
Sweet things:
Source of protein
Added salt:
Added sugar:
How many units of these drinks do you consume per day?
Tea:
Coffee:
Fruit juice:
Water:
Soft drinks:
Do you suffer from food allergies? Yes
No
Do you suffer from eating disorders? Bingeing: Yes
Under eating: Yes
No
Overeating: Yes
No
No
Do you smoke? Yes
No
Do you drink alcohol? Yes
Do you exercise? Yes
If yes, how many per day?
No
No
What is your skin type? Dry
If yes, how many units per day?
Occasional
Oily
Irregular
Normal
Hay Fever
Asthma
Regular
Young
Do you suffer/have you suffered from: Dermatitis
Allergies
Others:
Acne
Types of exercise:
Mature
Eczema
Psoriasis
Skin cancer
Treatment: (select if/where appropriate):
Mechanical Massage (G5)
Microcurrent
Galvanism
Vacuum suction
Faradism
Unit 823 Provide Body Electrotherapy Treatments
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BODY ANALYSIS
Height:
Weight:
Types of Fat:
Body type/conditions:
Postural conditions:
MEASUREMENTS:
Upper chest (under the arms):
Maximum chest:
Below bust:
Waist:
Hips:
Maximum buttocks (on hairline):
Top of thigh: Right:
Left:
1 inch/2cm above knee: R:
L:
Maximum calf muscle: R:
L:
Ankle: R:
L:
Middle of upper arm: R:
L:
Middle of lower arm: R:
L:
Wrist: R:
L:
MUSCLE TEST (select if/where appropriate):
Quadriceps: Excellent
Good
Average
Hamstrings: Excellent
Good
Average
Biceps:
Excellent
Good
Average
Triceps:
Excellent
Good
Average
Abdominal: Excellent
Good
Average
TESTS
Nerve (tactile) sensitivity test: Yes
Heat (thermal) sensitivity test: Yes
Unit 823 Provide Body Electrotherapy Treatments
Poor
Poor
Poor
Poor
Poor
No
No
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Treatment details:
Client feedback:
After/Home care advice given:
Client’s signature.................................................................
Learner’s signature...................…………….........................
Unit 823 Provide Body Electrotherapy Treatments
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